Provider Demographics
NPI:1629329487
Name:SMITH, LAURA ZOE ENTIN (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ZOE ENTIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 SPRUCE ST
Mailing Address - Street 2:1 CATHCART
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-6130
Mailing Address - Country:US
Mailing Address - Phone:215-829-2010
Mailing Address - Fax:
Practice Address - Street 1:800 SPRUCE ST
Practice Address - Street 2:1 CATHCART
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6130
Practice Address - Country:US
Practice Address - Phone:215-829-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA057514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant